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Frequently Asked Questions: Anxiety and Stress

Q: What is anxiety?

A: All children experience anxiety from time to time. This is normal and expected. Anxiety refers to a state of negative arousal, during which an individual feels fearful, worried, or apprehensive. When feeling anxious, a young person can experience negative thoughts like, "I'm going to fail," "Mom is going to get hurt," "Everyone will laugh at me." Along with negative thoughts, the individual may also experiences physical sensations, such as racing heart, nausea, shortness of breath, and chest pain. Children and adolescents, particularly young children, may not be very good at identifying and expressing how they feel. Instead of saying, "I feel anxious," a child may report having an upset stomach or feeling bad. More

Q: Are there different types of anxiety?

A: According to the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), there are several different types of Anxiety Disorders:

  • Panic Disorder, which is diagnosed when people are having repeated Panic Attacks
  • Specific Phobias are significant fears of particular objects or situations (e.g., spiders, flying, needles), which often cause people to avoid these objects and situations
  • Social Phobia is significant fear of social or performance situations
  • Obsessive-Compulsive Disorder is where people have recurrent thoughts or obsessions about things (e.g., germs) and then are compelled to perform rituals or routines (e.g., hand washing, not stepping on cracks, checking locks, etc.)
  • Posttraumatic Stress Disorder is when people re-experience a very traumatic event (e.g., sexual abuse, witnessing someone being badly harmed) and feel fearful and make efforts to avoid things that remind them of the trauma
  • Generalized Anxiety Disorder is when people are excessively anxious and worried about a variety of things for at least a six month period of time.

Q: What if my child or adolescent is anxious, but does not meet criteria for an Anxiety or Adjustment Disorder?

A: If your child or adolescent does not meet criteria for an Anxiety or Adjustment Disorder, anxiety symptoms may still negatively impact his, her, or your family's life. Young people can sometimes have difficulties in response to stressful events, such as changing school, parents getting divorced or remarried, deployment, etc. Some amount of anxiety is normal and adaptive. It is important to communicate this to young people, and support them through difficult times. Child/adolescent self-care and stress management information posted on this site may be helpful for young people to help them cope with the normal ups and downs of life. If you have any doubt about whether or not your child or adolescent is suffering from a mental disorder, consult with your pediatrician or a mental health provider.

Q: What is stress?

A: Stress is roughly the opposite of relaxation. It is also the opposite of feeling calm, and quite different than a feeling of well-being. It can be defined in terms of four components:1

  1. A stressor (some trigger) is present (e.g., deployment, divorce, changing schools, uncertainties).
  2. The young person evaluates the situation as stressful. Not everyone views the same events or situations as stressors.
  3. The young person attempts to cope with the stressful demands. Not everyone copes with stressors in the same manner, therefore some young people will be more effective at handing stressors than others.
  4. A complex set of reactions takes place both in the mind and the body. These stress reactions are experienced differently.

Information about different types of stress

Adolescents and children, particularly young children, may have difficulties expressing their feelings. Unlike an adult, they may not report, "I feel stressed." Instead, they may report stomach aches, exhibit behavior problems, have difficulty sleeping, or withdraw socially. More

Stress Test Parenting Quiz: Is your teenager stressed out?

Q: How common are Anxiety Disorders?

A: They are common. It is estimated that 6-18% of children suffer from an Anxiety Disorder.4, 5 Rates of Anxiety Disorders vary depending upon age. For instance, young children are more likely to suffer from Separation Anxiety Disorder than older children.4, 5 However, the prevalence of other Anxiety Disorders tends to increase with age.5 Girls are more likely to be affected than boys.6 Just like adults, children worry. A survey by KidsHealth® of 1,004 children, ages 9-13 year olds, found that their most common worry is grades, followed by appearance, problems at home, and being liked by others. More

Q: What treatments are helpful for Anxiety Disorders?

A: In general, cognitive behavioral treatments (CBT) are frequently used to treat Anxiety Disorders in children and adolescents.5 CBT is designed to help anxious youth change unhealthy thinking that contributes to anxiety. Cognitive strategies are also used to help the child or adolescent recognize anxious thoughts, manage anxiety, and cope with anxiety-producing situations. According to Division 53 of the American Psychological Association several specific forms of short-term psychotherapy have been shown to be beneficial in the treatment certain Anxiety Disorders in children and teens:

Specific Phobia

The following are well-established treatments for specific phobias in young people:

  • Participant Modeling involves a model (e.g. therapist, friend, or peer) who demonstrates fearlessness and coping responses when confronting a feared situation or object. Then the model assists the child in practicing approaching and confronting the feared situation or object. This is done slowly, at a pace the child is comfortable with, sometimes over many weeks.
  • Reinforced Practice involves exposure, or practicing approaching and confronting a feared situation or object, and rewards when the child does so. Again, this may take some time.
  • Cognitive behavior therapy is designed to help anxious youth change unhealthy thinking that contributes to anxiety. Cognitive strategies are also used to help the child or adolescent recognize anxious thoughts, manage anxiety, and cope with anxiety-producing situations.
  • Systematic desensitization involves having the child or adolescent imagine his/her feared object or situation while he/she is engaged in a response that is incompatible with anxiety (e.g. relaxation or play), instead of physically exposing them to the feared object or situation.

Generalized Anxiety Disorder

The following therapies have been shown to be effective for treating Generalized Anxiety Disorder in young people.

  • Cognitive behavior therapy is designed to help anxious youth change unhealthy thinking that contributes to anxiety. Cognitive strategies are also used to help a child or adolescent recognize anxious thoughts, manage anxiety, and cope with anxiety-producing situations.
  • Exposure involves practicing approaching and confronting a feared situation or object. This is hard to do initially but becomes easier and easier with continued practice. Recall how you got over some of your fears (diving boards, riding a bike, learning to drive). Each time you did it, there was less fear. And at some point, you even started enjoying the previously feared activity. Knowing this it is critical to help your children face their fears and to keep doing so until the fear lessens.
  • Family Anxiety Management (FAM) teaches parents to reward a child for confronting a feared situation or object, and ignore excessive complaining when confronted with a feared situation or object.
  • Participant Modeling involves a model (e.g. therapist, friend, or peer) who demonstrates fearlessness and coping responses when confronting a feared situation or object. Then the model assists the child in practicing approaching and confronting the feared situation or object.
  • Reinforced Practice involves exposure, or practicing approaching and confronting a feared situation or object, and rewards when the child does so.
  • Relaxation training teaches young people to let go of physical and psychological tension.

Separation Anxiety Disorder

The following therapies have been shown to be likely help for treating Separation Anxiety Disorder in young people.

  • Family Anxiety Management (FAM) teaches parents to reward the child for confronting a feared situation or object, and ignore excessive complaining when confronted with a feared situation or object. This treatment is useful in treating Separation Anxiety Disorder for children 7 to 10 years of age, however it appears less useful for children and adolescents 11 to 14 years of age. Cognitive behavior therapy is designed to help anxious youth change unhealthy thinking that contributes to anxiety. Cognitive strategies are also used to help the child or adolescent recognize anxious thoughts, manage anxiety, and cope with anxiety-producing situations.
  • Exposure involves practicing approaching and confronting a feared situation or object. This is hard to do initially but becomes easier and easier with continued practice. Recall how you got over some of your fears (diving boards, riding a bike, learning to drive). Each time you did it, there was less fear. And at some point, you even started enjoying the previously feared activity. Knowing this it is critical to help children face their fears and to keep doing so until the fear lessens.
  • Reinforced Practice involves exposure, or practicing approaching and confronting a feared situation or object, and rewards when the child does so.
  • Systematic desensitization involves having the child or adolescent imagine a feared object or situation while engaged in a response that is incompatible with anxiety (e.g. relaxation or play), instead of physically exposing them to the feared object of situation.
  • Relaxation training teaches young people to let go of physical and psychological tension.

Although medications are sometimes used to treat Anxiety Disorders in children and adolescents, data supporting their efficacy and safety with young people is limited.4 According to the Academy of Child and Adolescent Psychiatry, medication should not be used as the sole intervention, but as an adjunct to psychotherapeutic interventions.Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are most commonly used to treat pediatric Anxiety Disorder. Benzodiazepines, a class of anti-anxietymedication, may be used on a short-term basis for anxiety symptoms. Less commonly used anxiolytics include buspirone and beta-blockers.8 It is important to consider potential side-effects compared to the benefits of medications. Not all medications work the same for everyone; therefore it is important that you consult with your pediatrician or a child psychiatrist to determine which medication (if any) is best for your child. Learn more about anxiety medications and children.

Questions to Ask your child's doctor about psychiatric medications.

Q: What resources are available for stress management?

A: Most reactions to life stressors are considered normal and do not develop into a mental disorder. Therefore, becoming educated, seeking support, and taking steps to maintain a healthy lifestyle are effective coping strategies. Check out the Stress and Self-Care tools offered on this site. If your child or adolescent develops a disorder, such as depression or anxiety, treatment is available for specific disorders. Check out the resources for specific disorders available on this site.

Q: Does my child or adolescent have to see a specialist in order to get help for anxiety?

A: No. Your PCM may recommend and prescribe medications for your child's anxiety symptoms. You can discuss your concerns with your PCM during your general medical appointment.Caregivers and young people can learn about a number of resources for coping with anxiety and stress. Check out the self-help tools offered on this site. If your provider believes it is necessary to seek specialty care, they will be able to assist you to that next level of care. Sometimes family, friends, or clergy can be good sources of support when facing a challenging behavioral change.

Q: How do I locate a specialist in my area?

A: You can contact any of the following organizations, which have referral capabilities:

Q: Does TRICARE cover treatment for anxiety?

A: TRICARE policy for reimbursement requires that services must be medically necessary for a diagnosed psychological disorder. The disorder must be one referenced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and must be of a severity not only to cause the patient distress but also to interfere with the patient's usual activities.

TRICARE beneficiaries are eligible for eight behavioral health care visits per year without a referral or pre-authorization. Active duty military personnel always need a referral for care outside a military treatment facility. More

References:

1Lazarus, R. S. (1993). From psychological stress to the emotions: A history of changing outlooks. Annual Review of Psychology 44, 1-21.

2Voelkner, R. (2004). Stress, sleep loss, and substance abuse create potent recipe for college depression. Journal of the American Medical Association 291 (18), 2177-2179.

3McQuaid, J.R., Brown, S.A., Aarons, G.A., Smith, T.L., Patterson, T.L, Schuckit, M.A. (2000). Correlates of life stress in an alcohol treatment sample. Addictive Behaviors 25(1), 131-137.

4Christopherson, E. R., & Mortweet, S. L. (2005).Treatments that work with children. Washington, DC: American Psychological Association.

5Laurent, J., & Potter, K. I. (1998). Anxiety-related difficulties.In. T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 239-260). New York: Plenum Press.

6U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services.

7National Institute of Health, Medical Encyclopedia. What do children worry about? : A fact sheet for Teachers and Parents. Accessed 5/17/06

8American Academy of Child and Adolescent Psychiatry (1997). Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 36 (10 suppl).